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Alves AMCV, de Brito ÉHS, de Araújo MFM, de Hollanda Celestino JJ, Leite ACRDM, Cruz GS, Azevedo NF, Rodrigues CF. Antifungal Susceptibility and Candida sp. Biofilm Production in Clinical Isolates of HIV-Positive Brazilian Patients under HAART Therapy. Biomedicines 2024; 12:310. [PMID: 38397912 PMCID: PMC10886575 DOI: 10.3390/biomedicines12020310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/25/2024] Open
Abstract
The aim of the present study was to characterize biofilms formed by Candida spp. clinical isolates (n = 19), isolated from the oral mucosa of HIV-positive patients. For characterizing the biofilms formed by several Candida sp. strains, isolated from HIV-positive patients, in terms of formed biomass, matrix composition and antifungal susceptibility profile, clinical isolates (n = 19) were collected from oral mucosa and identified. The biofilm of the samples was cultured with fluconazole (1250 mg/L), voriconazole (800 mg/L), anidulafungin (2 mg/L) or amphotericin B (2 mg/L). Afterwards, the quantification of the total biomass was performed using crystal violet assay, while the proteins and carbohydrates levels were quantified in the matrix. The results showed a predominance of C. albicans, followed by C. krusei. Around 58% of the Candida spp. biofilm had susceptibility to fluconazole and voriconazole (800 mg/L), 53% to anidulafungin and 74% to amphotericin B. C. krusei presented both the lowest and the highest biofilm matrix contents in polysaccharides and proteins. The low resistance to antifungal agents reported here was probably due to the fact that none of the participants had a prolonged exposure to these antifungals. A predominance of less virulent Candida spp. strains with low or no resistance to antifungals was observed. This can be attributed to a low fungal selective pressure. This most probably happened due to a low fungal selective pressure but also due to a good adherence to HAART therapy, which guarantees a stable and stronger immune patient response.
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Affiliation(s)
- Anelise Maria Costa Vasconcelos Alves
- Department of Morphology, Faculty of Medicine, Federal University of Ceará, Fortaleza 60430-170, Ceará, Brazil;
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal;
- ALiCE—Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal
| | - Érika Helena Salles de Brito
- Institute of Health Sciences, University of International Integration of Afro-Brazilian Luso-Phony, Redenção 62790-000, Ceará, Brazil; (É.H.S.d.B.); (J.J.d.H.C.); (A.C.R.d.M.L.)
| | | | - Juliana Jales de Hollanda Celestino
- Institute of Health Sciences, University of International Integration of Afro-Brazilian Luso-Phony, Redenção 62790-000, Ceará, Brazil; (É.H.S.d.B.); (J.J.d.H.C.); (A.C.R.d.M.L.)
| | - Ana Caroline Rocha de Melo Leite
- Institute of Health Sciences, University of International Integration of Afro-Brazilian Luso-Phony, Redenção 62790-000, Ceará, Brazil; (É.H.S.d.B.); (J.J.d.H.C.); (A.C.R.d.M.L.)
| | - Gabriela Silva Cruz
- Institute of Health Sciences, University of International Integration of Afro-Brazilian Luso-Phony, Redenção 62790-000, Ceará, Brazil; (É.H.S.d.B.); (J.J.d.H.C.); (A.C.R.d.M.L.)
| | - Nuno Filipe Azevedo
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal;
- ALiCE—Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal
| | - Célia Fortuna Rodrigues
- LEPABE—Laboratory for Process Engineering, Environment, Biotechnology and Energy, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal;
- ALiCE—Associate Laboratory in Chemical Engineering, Faculty of Engineering, University of Porto, 4200-465 Porto, Portugal
- 1H-TOXRUN—One Health Toxicology Research Unit, Cooperativa de Ensino Superior Politécnico e Universitário—CESPU, 4585-116 Gandra PRD, Portugal
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Molecular characterization of Enterobacter aerogenes isolated from urinary tract infections in Iran. Acta Trop 2022; 232:106485. [PMID: 35487296 DOI: 10.1016/j.actatropica.2022.106485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/24/2022]
Abstract
The prevalence of multidrug-resistant Enterobacter aerogenes strains in UTIs is increasing. Therefore, the purpose of this study was to examine the mechanisms of resistance in Enterobacter aerogenes strains isolated from the urinary tract of infected patients. To achieve this goal, 786 urine samples from Shahrekord, Iran, were collected from June 2019 to February 2020. After isolating and identifying E. aerogenes samples, antibiotic susceptibility testing was done on the strains using Kirby-Bauer's disk diffusion method. The biofilm formation assays were performed to study the link between antibiotic resistance and biofilm formation and virulence genes. As a result, amongst the 786 urine samples, 50 strains were identified as E. aerogenes. The lowest rate of resistance was observed with imipenem (30%). This study also reports that all the strains of E. aerogenes are biofilm producers, with 50% of isolates producing a large amount, 30% a moderate amount, and 20% a small amount of biofilm. 42% were identified in the phenotypic study of ESBLs. In the PCR test, (64%) produced broad-spectrum beta-lactamases. Prevalence of qnrC, qnrB, qnrA, tetA, tet B, acc(3)IIa, acc(2)IIa, ant(2)Ia and Sul1 in strong producing isolates reported 100%, 80.95%,% 58.14, 87.5%, 81.58%, 86.67%, 82.14, 81.48% and 90% respectively. In the statistical analysis based on the chi-square test, a statistically significant relationship was reported between qnrA, qnrB, tetA, tetB, Sul1, ant(2)Ia, ant(3)I, aac(3)II, and biofilm formation. Resistance to cephalothin, ceftriaxone, cefotaxime and ceftazidime were reported 40%, 34%, 30% and 30%, respectively. Out of 50 Enterobacter aerogenes, 32 isolates (64%) were identified in the phenotypic study of ESBLS, prevalence of blaCTX-M, blaTEM and blaSHV reported 30%, 20% and 14% respectively. There is a significant relationship between resistance to ceftriaxone and blaCTX-M. Prevalence of csgA, ybtS, markD, rmpA, csgD and fimH in strong biofilm formation isolates reported 84%, 83.33%, 80%, 80%, 80% and 66% respectively. The chi-square test showed a statistically significant relationship between biofilm production and resistance genes fimH, csgA, csgD, ybtS, and mrkD. The findings of this study indicate that the ability to produce biofilms is associated with the increase of antibiotic resistance and virulence genes. These agents enable bacteria to produce biofilms that ultimately lead to colonization and bacterial survival in the body.
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Fanou BA, Klotoe JR, Dougnon V, Assogba P, Agbodjento E, Koudokpon CH, Fah L, Sintondji K, Kpoze R, Loko F. Efficacy of Extracts of Cyanthillium Cinereum, Khaya senegalensis and Lippia multiflora on Candida Strains Isolated From Urine Samples in Benin (West Africa). FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.890296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The search for new bioactive molecules with antifungal properties to combat resistance to classical antifungals represents a great challenge. This study aimed to explore the virulence factors and resistance profile of Candida species isolated from urine samples in Benin and the in vitro efficacy of organic extracts of Cyanthillium cinereum (L.) H.Rob., Lippia multiflora Moldenke and Khaya senegalensis (Desv.) A.Juss. on the growth of these Candida spp. The study focused on Candida strains isolated from urine samples collected from patients admitted to the bacteriological analysis laboratories of hospitals in Southern Benin. The sensitivity of these strains to classical antifungal agents was determined by the simple diffusion method. Their pathogenicity was investigated via several virulence factors (gelatinase, hemolysin, hydrophobicity, adhesin, biofilm and lecithinase). The in vitro efficacy of the aqueous, ethanolic and hydro-ethanolic extracts of the plants on Candida albicans ATCC 90028 and on six clinical strains was evaluated by the method of determination of the inhibition diameters. The results obtained showed that 51 different Candida strains were isolated from the collected urine samples with a respective predominance of Candida albicans (52.94%) and Candida glabrata (17.64%) species. All identified species were sensitive to amphotericin B and nystatin but 20% are resistant to fluconazole and present 15 different resistance profiles. Six different virulence factors were identified with a high frequency of hydrophobicity (96.08%) and adhesin (94.12%). Antifungal tests revealed that at 100 mg/mL the plant extracts were active on the tested strains with better activity for Cyanthilium cinereum and Khaya senegalensis. Cyanthilium cinereum, Khaya senegalensis and Lippia multiflora showed antifungal activity on virulent Candida strains suggesting the possibility to explore them further for the discovery of new antifungal molecules.
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Faria-Gonçalves P, Rolo J, Gaspar C, Palmeira-de-Oliveira R, Martinez-de-Oliveira J, Palmeira-de-Oliveira A. Virulence Factors as Promoters of Chronic Vulvovaginal Candidosis: A Review. Mycopathologia 2021; 186:755-773. [PMID: 34613569 DOI: 10.1007/s11046-021-00592-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 09/09/2021] [Indexed: 01/09/2023]
Abstract
INTRODUCTION The vast majority of the species of the genus Candida spp. is commensal in humans; however, some are opportunistic pathogens that can cause infection, called candidosis. Among the different types of candidosis, we highlight the vulvovaginal (VVC) which can occur in two main clinical variants: chronic (cVVC) and episodic or sporadic. The incidence of cVVC has been worrying the scientific community, promoting the research on genotypic and phenotypic causes of its occurrence. We summarize important findings on factors that favor chronic vulvovaginal candidosis with respect to molecular epidemiology and the expression of various virulence factors, while clarifying the terminology involving these infections. AIM AND METHODOLOGY The aim of this review was to gather research that linked virulence factors to VVC and its persistence and recurrence, using two databases (Pubmed and Google Scholar). Predisposing factors in women for the occurrence of cVVC and some studies that refer new preventive and alternative therapies were also included, where appropriate. RESULTS AND DISCUSSION Several studies have been shedding light on the increasing number of persistence and recurrences of VVC. The expression of virulence factors has been related to both chronic forms of VVC and antifungal resistance. Other studies report mutations occurring in the genome of Candida spp. during the infection phase which may be important indications for new therapies. The introduction of preventive therapies and new therapies has revealed great importance and is also highlighted here.
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Affiliation(s)
- Paula Faria-Gonçalves
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal.,Faculty of Medicine, University Mandume Ya Ndemufayo, Lubango, Angola.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Joana Rolo
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal.
| | - Carlos Gaspar
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Products Research and Development Lda, Covilhã, Portugal
| | - Rita Palmeira-de-Oliveira
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Products Research and Development Lda, Covilhã, Portugal.,Center for Neuroscience and Cell Biology, University of Coimbra, Rua Larga, 3004-504, Coimbra, Portugal
| | - José Martinez-de-Oliveira
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal
| | - Ana Palmeira-de-Oliveira
- Health Sciences Research Center, University of Beira Interior, Av. Infante D. Henrique, 6200-506, Covilhã, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Health Products Research and Development Lda, Covilhã, Portugal
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Foessleitner P, Petricevic L, Boerger I, Steiner I, Kiss H, Rieger A, Touzeau‐Roemer V, Farr A. HIV infection as a risk factor for vaginal dysbiosis, bacterial vaginosis, and candidosis in pregnancy: A matched case-control study. Birth 2021; 48:139-146. [PMID: 33462893 PMCID: PMC8247846 DOI: 10.1111/birt.12526] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 12/26/2020] [Accepted: 12/28/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND This study aimed to evaluate the vaginal microbiota of HIV-positive pregnant women relative to HIV-negative controls, and to compare their risk of vaginal dysbiosis, bacterial vaginosis, and vulvovaginal candidosis (VVC). METHODS This is a nested matched case-control study that analyzed data from women who received pregnancy care at our center from 2003 to 2014. Women routinely underwent screening for asymptomatic vaginal infections using phase microscopy on Gram-stained smears. HIV-positive women were assigned to the case group, and HIV-negative women were assigned to the control group. Cases and controls were matched in a 1:4 ratio. Logistic regression was used to test whether HIV infection was associated with vaginal dysbiosis (Nugent score 4-6), BV (Nugent score 7-10), or VVC. RESULTS One hundred and twenty-seven women were assigned to the case group, and 4290 were assigned to the control group (including 508 matched controls). Dysbiosis or BV was found in 29.9% of the cases and 17.6% of the controls. Women in the case group had increased risk of vaginal dysbiosis or BV (odds ratio [OR] 2.09, 95% confidence interval [CI], 1.30-3.32, P = .002). The risk of VVC was also higher in the case group (OR 2.14, 95% CI, 1.22-3.77, P = .008). The incidence of preterm birth did not differ significantly between the groups (cases: 8.7%; controls: 10%, P = .887). CONCLUSIONS HIV-positive women are at risk of vaginal dysbiosis, BV, and VVC during pregnancy. As imbalances of the vaginal microbiota can lead to preterm birth, screening and treatment of HIV-positive pregnant women are warranted.
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Affiliation(s)
- Philipp Foessleitner
- Department of Obstetrics and GynecologyDivision of Obstetrics and Feto‐maternal MedicineMedical University of ViennaViennaAustria
| | - Ljubomir Petricevic
- Department of Obstetrics and GynecologyDivision of Obstetrics and Feto‐maternal MedicineMedical University of ViennaViennaAustria
| | - Isabell Boerger
- Department of Obstetrics and GynecologyDivision of Obstetrics and Feto‐maternal MedicineMedical University of ViennaViennaAustria
| | - Irene Steiner
- Center for Medical StatisticsInformatics and Intelligent Systems (IMS)Medical University of ViennaViennaAustria
| | - Herbert Kiss
- Department of Obstetrics and GynecologyDivision of Obstetrics and Feto‐maternal MedicineMedical University of ViennaViennaAustria
| | - Armin Rieger
- Department of DermatologyMedical University of ViennaViennaAustria
| | | | - Alex Farr
- Department of Obstetrics and GynecologyDivision of Obstetrics and Feto‐maternal MedicineMedical University of ViennaViennaAustria
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Bonfim-Mendonça PDS, Tobaldini-Valério FK, Capoci IR, Faria DR, Sakita KM, Arita GS, Negri M, Kioshima ÉS, Svidzinski TI. Different expression levels of ALS and SAP genes contribute to recurrent vulvovaginal candidiasis by Candida albicans. Future Microbiol 2021; 16:211-219. [PMID: 33595345 DOI: 10.2217/fmb-2020-0059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Aim: To study the behavior of Candida albicans in women with vulvovaginal candidiasis (VVC), recurrent VVC (RVVC) and asymptomatic (AS), regarding adhesion on HeLa cells and their ability to express secreted aspartic proteinases (SAP) genes, agglutinin-like sequence (ALS) genes and HWP1. Materials & methods: The adhesion of Candida albicans to HeLa cells was evaluated by colony-forming units, and the expressed genes were evaluated by qRT-PCR. Results: AS and VVC isolates showed greater ability to adhere HeLa cells when compared with RVVC isolate. Nevertheless, RVVC isolate exhibited upregulation of a large number of genes of ALS and SAP gene families and HWP1 gene. Conclusion: The results demonstrated that RVVC isolate expressed significantly important genes for invasion and yeast-host interactions.
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Affiliation(s)
- Patrícia de S Bonfim-Mendonça
- Departamento de Análises Clínicas e Biomedicina. Laboratório Micologia Médica. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil.,Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Flávia K Tobaldini-Valério
- Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Isis Rg Capoci
- Departamento de Análises Clínicas e Biomedicina. Laboratório Micologia Médica. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil.,Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Daniella R Faria
- Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Karina M Sakita
- Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Glaucia S Arita
- Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Melyssa Negri
- Departamento de Análises Clínicas e Biomedicina. Laboratório Micologia Médica. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Érika S Kioshima
- Departamento de Análises Clínicas e Biomedicina. Laboratório Micologia Médica. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil.,Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
| | - Terezinha Ie Svidzinski
- Departamento de Análises Clínicas e Biomedicina. Laboratório Micologia Médica. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil.,Programa de Pós-graduação em Biociências e Fisiopatologia. Universidade Estadual de Maringá. Maringá, Paraná, CEP: 87020-900, Brazil
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Hagiwara D, Takahashi H, Takagi H, Watanabe A, Kamei K. Heterogeneity in Pathogenicity-related Properties and Stress Tolerance in Aspergillus fumigatus Clinical Isolates. Med Mycol J 2019; 59:E63-E70. [PMID: 30504617 DOI: 10.3314/mmj.18-00007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stress responses and pathogenicity have been extensively studied in Aspergillus fumigatus, the main causative pathogen of life-threatening aspergillosis. The heterogeneity in this pathogen's biology has recently attracted increasing attention. In the present work, we used 16 clinically isolated strains to investigate several properties relevant to the pathogenicity of A. fumigatus, namely, gliotoxin production, elastase activity, hypoxia growth, adaptation to iron-limiting conditions, and growth upon nitrosative, oxidative, and high osmotic stresses. The range of phenotypes was diverse across the strains, with gliotoxin production and elastase activity being negatively correlated at an intermediate index (R=-0.4717). Notably, there were strains that showed extraordinary high production of gliotoxin or elastase activity and hypersensitivity to nitrosative or oxidative stresses. Clustering analysis showed that the 7 potentially pathogenicity-related phenotypes were not correlated with the genetic sub-group or pathotype. These results contribute to the growing awareness of the genetic and phenotypic diversity in A. fumigatus isolates.
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Affiliation(s)
- Daisuke Hagiwara
- Medical Mycology Research Center, Chiba University.,Faculty of Life and Environmental Sciences, University of Tsukuba
| | - Hiroki Takahashi
- Medical Mycology Research Center, Chiba University.,Molecular Chirality Research Center, Chiba University
| | - Hiroshi Takagi
- Graduate School of Science and Technology, Nara Institute of Science and Technology
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Rodríguez-Cerdeira C, Gregorio MC, Molares-Vila A, López-Barcenas A, Fabbrocini G, Bardhi B, Sinani A, Sánchez-Blanco E, Arenas-Guzmán R, Hernandez-Castro R. Biofilms and vulvovaginal candidiasis. Colloids Surf B Biointerfaces 2018; 174:110-125. [PMID: 30447520 DOI: 10.1016/j.colsurfb.2018.11.011] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 11/04/2018] [Accepted: 11/05/2018] [Indexed: 01/18/2023]
Abstract
Candida species, including C. albicans, are part of the mucosal flora of most healthy women, and inhabit the gastrointestinal and genitourinary tracts. Under favourable conditions, they can colonize the vulvovaginal mucosa, giving rise to symptomatic vulvovaginal candidiasis (VVC). The mechanism by which Candida spp. produces inflammation is unknown. Both, the blastoconidia and the pseudohyphae are capable of destroying the vaginal epithelium by direct invasion. Although the symptoms are not always related to the fungal burden, in general, VVC is associated with a greater number of yeasts and pseudohyphae. Some years ago, C. albicans was the species most frequently involved in the different forms of VVC. However, infections by different species have emerged during the last two decades producing an increase in causative species of VVC such as C. glabrata, C. parapsilosis, C. krusei and C. tropicalis. Candida species are pathogenic organisms that have two forms of development: planktonic and biofilm. A biofilm is defined as a community of microorganisms attached to a surface and encompassed by an extracellular matrix. This form of presentation gives microorganisms greater resistance to antifungal agents. This review, about Candia spp. with a special emphasis on Candida albicans discusses specific areas such as biofilm structure and development, cell morphology and biofilm formation, biofilm-associated gene expression, the cell surface and adherence, the extracellular matrix, biofilm metabolism, and biofilm drug resistance in vulvovaginitis biofilms as an important virulence factor in fungi.
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Affiliation(s)
- Carmen Rodríguez-Cerdeira
- Efficiency, Quality and Costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain; Dermatology Department, Hospital do Meixoeiro and University of Vigo, Vigo, Spain; European Women's Dermatologic and Venereologic Society (EWDVS), Vigo, Spain.
| | - Miguel Carnero Gregorio
- Efficiency, Quality and Costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain; Department of Biochemistry, Genetics and Immunology, University of Vigo, Vigo, Spain
| | - Alberto Molares-Vila
- Efficiency, Quality and Costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain; Department of Department of Analytical & Food Chemistry, Universidade de Vigo (UVIGO), Spain
| | - Adriana López-Barcenas
- Efficiency, Quality and Costs in Health Services Research Group (EFISALUD), Galicia Sur Health Research Institute (IIS Galicia Sur), SERGAS-UVIGO, Spain; Mycology Service, Hospital Manuel Gea González, Mexico City, Mexico
| | | | | | - Ardiana Sinani
- Dermatology Service, Military Medical Unit, University Trauma Hospital, Tirana, Albania
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